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Allergic Rhinitis

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Allergic Rhinitis Guidelines for Clinical Care Quality Department Ambulatory Allergic Rhinitis Allergic Rhinitis Guideline Team Team Leader Patient population: Adults and pediatrics David A DeGuzman, MD General Medicine Objectives: Assist in the diagnosis and cost-effective treatment of allergic rhinitis. Team Members Catherine M Bettcher, MD Key Aspects & Recommendations: Family Medicine Diagnosis. Allergic rhinitis is an antigen-mediated inflammation of the nasal mucosa that may extend R Van Harrison, PhD into the paranasal sinuses. Diagnosis is usually made by history and examination (“itchy, runny Medical Education sneezy, stuffy”). A symptom diary and a trial of medication may be helpful to confirm a diagnosis. Allergy testing is not commonly needed to make the diagnosis, but may be helpful for patients with Christine L Holland, MD multiple potential allergen sensitivities Allergy Therapy. The goal of therapy is to relieve symptoms. Lauren M Reed, MD 1. Avoidance of allergens is the first step [I A*]. (See text for details). If avoidance fails: Pediatrics 2. An over-the-counter (OTC), non-sedating antihistamine (loratadine [Claritin], cetirizine ([Zyrtec], Tami L Remington, PharmD fexofenadine [Allegra]) should be tried initially. They provide relief in most cases. They prevent Pharmacy and relieve nasal itching, sneezing, and rhinorrhea, and ocular symptoms, but tend to be less Mark A Zacharek, MD effective for nasal congestion [I A*]. If symptoms persist consider the following options: Otolaryngology 3. Other medications: • Intranasal corticosteroids (prescription and OTC) are the most potent medications available for [I A*] Initial Release treating allergic rhinitis . They control itching, sneezing, rhinorrhea, and stuffiness in most July, 2002 patients, and may help ocular symptoms. They have a relatively good long-term safety profile. Most Recent Major Update Generic intranasal corticosteroids for adults and children are: fluticasone (Flonase), now October, 2013 available OTC, triamcinolone acetonide (Nasalcort AQ), and flunisolide (Nasarel). • Oral decongestants (OTC) decrease swelling of the nasal mucosa which, in turn, alleviates Ambulatory Clinical nasal congestion [I A*]. They can be combined with oral antihistamines or other agents. Guidelines Oversight However, they are associated with appreciable side effects, especially in geriatric patients, and Grant Greenberg, MD, MA, should only be considered when congestion is not controlled by other agents. They are MHSA contraindicated with monoamine oxidase inhibitors (MAOIs), in uncontrolled hypertension, R. Van Harrison, PhD and in severe coronary artery disease and benign prostatic hyperplasia (BPH). • Leukotriene inhibitors (prescription-only) are less effective than intranasal corticosteroids [II Literature search service A*]. Consider using for patients who cannot tolerate first line agents or have co-morbid Taubman Medical Library asthma. • Intranasal cromolyn (OTC) is less effective than intranasal corticosteroids [II A*]. Cromolyn is a good alternative for patients who are not candidates for corticosteroids. It is most effective For more information: 734-936-9771 when used regularly prior to the onset of allergic symptoms. • Intranasal antihistamines (azelastine), while effective in treating the nasal symptoms associated with seasonal and perennial rhinitis and nonallergic vasomotor rhinitis, offer no therapeutic © Regents of the benefit over conventional treatment and incur additional cost [II A*]. University of Michigan • Ocular preparations should be considered for patients with allergic conjunctivitis who are not adequately controlled with or cannot tolerate an oral antihistamine or high dose nasal steroids, These guidelines should not be which do provide some improvement in ocular symptoms [II A*]. construed as including all proper methods of care or excluding Referral. Appropriate criteria for referral may include identification of specific allergens through testing, other acceptable methods of care intolerance to or failure of medical therapy, severe reactions, associated comorbid conditions, or desire for reasonably directed to obtaining the same results. The ultimate immunotherapy [I D*]. judgment regarding any specific clinical procedure or treatment Controversial Issues must be made by the physician in Medication vs. immunotherapy. A formal cost-benefit analysis of medication therapy versus light of the circumstances presented by the patient. immunotherapy (allergy shots) has not been performed; however, patients with moderate to severe symptoms that continue year round (seasonal or perennial allergic rhinitis) may benefit most from immunotherapy [II D*]. Allergen immunotherapy can be cost effective in children with asthma. Special Considerations. Certain patient groups (pediatrics, geriatrics, and severe asthmatics) may pose diagnostic and therapeutic challenges. * Strength of recommendation: I = generally should be performed; II = may be reasonable to perform; III = generally should not be performed. Level of evidence supporting a diagnostic method or an intervention: A=randomized controlled trials; B=controlled trials, no randomization; C=observational trials; D=opinion of expert panel. Figure 1. Treatment of Allergic Rhinitis Presumptive clinical diagnosis of allergic rhinitis? (Table 1) Discuss treatment options with patient (Tables 3 & 4). Yes Refer to specialist Referral indicated? (Table 5) No Initiate Treatment: 1) avoidance education 2) trial of medication (Table 6) 3) combination therapy Consider alternative diagnoses (Table 2) & evaluate as indicated. Consider: • Satisfactory response? No limited sinus CT scan • other diagnostic tests • treatment trial with alternative medication Yes • referral Follow up periodically. Discuss complications and potential long- term side effects (Tables 7 & 8). Table 1. Complications of Allergic Rhinitis General Concerns / Complications Adults Children Progression to and exacerbation of asthma X X Deviations in facial growth X Hyposmia X X Incisor protrusion X Malocclusion (crossbite, high palatal arch) X Nasal polyps X ? Middle ear effusion: hearing loss X X Sinusitis X X Sleep disorders X X X = Possible; ? = Uncertain 2 UMHS Allergic Rhinitis Guideline October 2013 Table 2. Symptoms and Signs Suggestive of Allergic Rhinitis Symptoms Seasonal, perennial or episodic (associated with exposure, e.g., cat) itching of eyes, ears, nose, palate; sneezing, nasal congestion, chronic sniffling, clear rhinorrhea, post nasal drip, pressure of nose or over paranasal sinus, morning cough. Red, watery eyes or ropy discharge. Family or personal history Atopic dermatitis, asthma, food allergy. Physical findings Ocular-allergic shiners, Dennie’s lines, scleral injection with corkscrewing of vessels, conjunctival erythema with possible cobblestoning. Nasal-transverse nasal crease (salute), congestion, pale pink or bluish mucosa, clear or thick mucoid discharge, structural issues such as deviated septum, turbinate hypertrophy, presence of nasal polyps, pharyngeal cobblestoning. Table 3. Alternative Diagnoses with Typical Characteristics Alternative Diagnosis Typical Characteristics Acute rhinosinusitis Facial pressure or pain, purulent nasal discharge; maxillary toothache; failure to respond to decongestants; fever or cough may be present; typically follows an allergy flare-up or a viral URI Chronic rhinosinusitis Facial pressure or pain, purulent discharge; fever often absent; may be present in addition to allergic rhinitis; symptoms may wax and wane over time; chronic hyposmia. Viral URI Self-limited course with symptoms (clear rhinorrhea, cough, ache, low grade fever) usually resolving within 3-7 days Structural abnormalities Include nasal septal deviation, nasal polyps, enlarged turbinates, adenoidal hypertrophy. Obstruction may be unilateral or bilateral and may or may not be seen on routine nasal examination. Gustatory rhinitis Clear rhinorrhea caused by hot (i.e. soup) or spicy foods, may have prominent nasal congestion as a symptom. Rhinitis medicamentosa Also called “rebound rhinitis;” caused by overuse of topical decongestants; diagnosis is easily made by history; may mask another underlying condition such as septal deviation or allergic rhinitis. Autonomic dysfunction Clear rhinorrhea, nasal obstruction, often depends on position (e.g., supine), may be episodic. (vasomotor rhinitis ) Pregnancy may exacerbate symptoms. Common in geriatric patients Medication side effect Common medications causing rhinitis symptoms include calcium channel blockers, beta blockers, ACE inhibitors and alpha blockers Atrophic rhinitis Also called “ozena”, caused by over-resection of nasal turbinate tissue or poor mucus production, resulting in nasal dryness and crusting. Foul odor may be present. Gastroesophageal reflux Under-recognized cause of post-nasal drip, cough, and globus sensation; hoarseness or frequent throat clearing may also be present Non-allergic rhinitis Post-nasal drip sensation often with morning phlegm 3 UMHS Allergic Rhinitis Guideline October 2013 Table 4. Advantages & Disadvantages of Treatment Options Treatment Options Advantages Disadvantages Environmental • Beneficial with minimal ongoing cost (may • Difficult to assess with certainty whether exposure Control / Avoidance be an initial cost to modify environment) has been controlled of Allergens • Effectiveness of chemical barriers requires repeated application? • Effective mite eradication requires repeated treatment Medications • Patient preference • Cost of medication
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